You may have seen the video: the patient confronting retail staff who ask her to wear a mask to enter the store, accusing them of human rights violations if they refuse her entry without a face covering.
Understand your legal position
When confronted by someone making demands or threats, it can be difficult to respond if you are not completely sure of your ground. You and your staff may have already been faced with unreasonable or aggressive patient behaviour and have come up with strategies for responding. If not, it can be helpful to think through some scenarios and make sure all staff know how to respond.
The question of mask wearing is covered by state public health orders and will vary from state to state. Whether or not masks are currently mandatory in your location, private practices are entitled to take reasonable steps to protect staff and other patients on the premises. This could include making it a condition of entry to wear a face covering. However, doctors would still have an obligation not to refuse care in an emergency.
If patients refuse to wear a mask, it is important to speak with them about their reason before you attempt to exclude them from your premises. It is not a violation of someone's human rights to ask them to wear a mask. However, you do need to avoid discriminating against patients who have a medical reason or disability that prevents them wearing a mask, or physically cannot remove the mask at times. Consider whether you can reasonably accommodate their needs, for example, can these patients wait somewhere other than the main waiting room?
Agreeing consistent policies and ensuring staff can confidently apply these will also help prepare for difficult encounters. It is helpful for practices to have a complaints policy. Other practice policies might deal with health and safety issues, or they might be around prescribing drugs of addiction. They might be agreements with individuals, for example “you agree to keep your scheduled appointments with the doctor” or “you will not telephone me after 8pm but rather call an ambulance if it is an emergency”. It is important policies are not discriminatory and do not deny patients care.
Always make sure you and your staff are safe. While general practices do report experiencing physical violence , they are more likely to report patient aggression, threats or complaints. However, if an encounter is violent, staff need to be able to stay calm, avoid further inflaming the situation and get help or get to a safe place if necessary. Your practice should have a documented safety policy and prepare for this situation.
It is a normal human response to want to defend ourselves against aggression or unreasonable behaviour. However, a better strategy is to try to just listen and not take it personally or start responding defensively. Giving the patient a chance to have their say may be enough to defuse the situation. It may also give you a better understanding of the source of their distress, which might be related to other stressors in their life.
Having heard the patient's concerns, try asking further clarifying questions to make sure you understand what the issue is. You could say “have I understood everything correctly?” or “is there anything I have missed?” Recognising the patient's concern and showing you are trying to understand can also help reduce their frustration.
Acknowledging someone's experience and expressing empathy can be very powerful. Even if you are not responsible for the situation, you can say you are sorry they had that experience and acknowledge their feelings. This is not an acknowledgment of legal responsibility and it might be another step in reducing the temperature of the encounter.
Avoid being manipulated
You need to be careful not to compromise patient care by giving in to demands that you feel are unreasonable. A patient may, for example, threaten to make a complaint or take legal action if you do not prescribe a particular drug, sign a certificate or give them particular treatment. Such patients may firmly believe they are entitled to this and you are unlikely to be able to persuade them otherwise.
This is where having clear boundaries or practice guidelines can help ensure patients get a consistent message about what is reasonable. Try to assist the patient within acceptable boundaries but be prepared to say no and seek help from a colleague if necessary.
Know your own limits
Being under stress ourselves may make us more likely to react in a way that escalates a situation. Strategies such as learning to take a few breaths and observe your own reactions can help you choose how you want to respond. It is also helpful to be aware of your body language and tone of voice – try to keep calm, use a neutral tone and adopt an open body posture.
Be aware if you are not able to respond effectively. Someone else might be better placed to deal with the situation. They may be more experienced, have a better relationship with the patient, or just be having a better day. Having a practice plan for such situations can include how to get someone else to step in if needed.
Ending patient care
Doctors are not compelled to continue the care of a patient where they hold genuine concerns about their own safety or the safety of staff. However, this consideration needs to be carefully balanced with any care required by the patient and with a doctor's obligation not to refuse care in an emergency.
You need to be confident steps taken by the doctors and the practice are reasonable in the circumstances, so it is useful to contact your MDO for advice before you seek to end a treating relationship.
Take care to document any confronting situations. As the patient or others may read notes in the patient record, make sure these are factual and objective. Sometimes it will also be appropriate to make a detailed incident report in the practice records, separate from the patient’s clinical notes.